Part I: Patient Information Form Completion – In-Person Screening

Part I: Patient Information Form Completion – In-Person Screening
Instructions: Using the following case scenario, complete the patient information form for this patient.
Complete all necessary information you would be responsible to complete even if not given it by the
patient. To facilitate effective communication with the patient, please use clarification, reflection and
restatement, in order to ensure all necessary information is recorded properly on the intake form.
Mr. Grant Charles arrived at the office today without an appointment. He signs in on the sign-in sheet,
and advises you the reason for the visit is chest pain. You immediately escort him into an examination
room. While you are doing the initial patient intake, the patient states he has been experiencing
symptoms of shortness of breath, tiredness, and numbness of the fingers and pain down his left arm. He
states he has a family history of heart disease and high sugar issues. You ask Mr. Charles what
medications he is currently taking. He tells you he is on a few medications for high blood pressure, and
high cholesterol. Mr. Charles indicates he was hospitalized for uncontrolled high blood pressure and for
placement of a stent in 1976 and 1984. His date of birth is 12/17/1956. His contact information is: 333
Plaza Court, Stephenson, OH 60089; Home #: 646-555-1434; Work: 889-209-5555, Ext. 333;
Employer: Ohio Electric, 6765 State St, Stephenson, OH, 60033; Insurance Info: Ohio Health Care;
Policy #: 336988300/Group #:HI1006. He is the subscriber for the insurance through his employer.